Analysis Manoeuvring Given that the rudder area ratio was within established norms, and the on-site steering gear performance tests on the SunnyBlossom were satisfactory, the vessel cannot be characterized as having slow and/or sluggish manoeuvring capabilities when operating under normal service conditions. However, the ship's manoeuvring characteristics can vary considerably depending on the following: the intensity and direction of wind; the wave action; the current; water depths if less than twice the vessel's draught; the cleanliness of the hull; and whether the ship is at an intermediate draught or has unusual trim. The SunnyBlossom was sailing at a reduced draught of 7.88m for Seaway navigation and had a small trim by the stern. The intermediate draught represented 86 per cent of the summer salt water draught of 9.15m. This draught is a principal design parameter in determining the appropriate rudder area for optimum manoeuvring considerations. Consequently, at this lesser draught, the vessel was likely to have been more responsive to helm changes than it would have been in deep water. The apprentice pilot commented on the sluggishness of the vessel when leaving the shallow channel exit from the Beauharnois Lock No.4 at a speed of only 6to 7kn. However, this is not an unusual phenomenon for a ship moving in a narrow channel such as the Beauharnois Canal, which has a depth of only 8.2m (seeAppendixB,Sketch1). This phenomenon would also exist for a ship navigating in the Lancaster Channel, where the depth of the water is only 0.5m more than in the Beauharnois Canal. Bank suction and squat effects can produce changes in the vessel's directional stability, affecting its response to the helm. Steering difficulties while operating in shallow waters had been experienced on a previous occasion when, on 16July1999, the vessel was on a similar voyage to Cornwall.7 Also, on 24April1999, the SunnyBlossom had ran hard aground in the U.S. section of the Seaway at the eastern entrance to Lake Ontario. On that occasion, environmental concerns were raised when the vessel required the lightening of its dangerous cargo. Although the helmsman had only served about two weeks on board the vessel, he had gained considerable prior experience as helmsman on a deep-sea chemical tanker. When his performance was questioned by the pilot, following some difficulty in steadying the vessel after a 33course change, the vessel had been travelling at the full sea speed of approximately 14kn, about 3kn more than full manoeuvring speed. It was the largest course change taken in a single turn during the helmsman's watch. At this maximum speed, the vessel's pivot point for manoeuvring was at its most forward position, making the vessel more responsive to helm changes. When the helmsman's ability to steer had been questioned by the pilot, the helmsman professed that he was fit to steer and, probably with a heightened state of alertness, he executed orders as required and with accurate course-keeping during the manoeuvres leading up to the grounding. Hydrodynamics In a channel bend, the path of the water mass is generally parallel to the outside bank of the channel. The direction of the current may be variable inside the bend and the current may be weaker. When a ship is negotiating a bend in a channel, it is possible to get into a position where the ship is influenced by currents of differing strengths. The bow can be influenced by the strong outside bend current while the after body is in the weaker current. This situation creates a turning moment that opposes the direction of the intended turn and, if it is not anticipated with appropriate helm and power, the vessel may not come around in sufficient time to clear the bend. When a ship is negotiating a bend in a channel, it is better to keep to the inside of the bend so that the bow does not enter the area of stronger current that occurs near the outside of the bend. In shallow water, the problem is compounded. The Venturi effect of water being forced under the bow, and the build-up of water ahead of the ship, will produce a squat by the bow on a vessel with a large block coefficient, and by the stern on a vessel with finer lines. When the vessel squats by the bow, the theoretical pivot point of the ship will also move further aft. In addition to the possibility of grounding forward due to squat, there also exists the possibility of a loss of directional stability that can cause the vessel to sheer to one side. If the helmsman allows a small swing to develop, longitudinal pressure forces will be brought to bear on the bow and this will augment the rate of swing. Counter helm to correct the swing may be sluggish because the steering lever is reduced.8 At full-ahead speed, the theoretical pivot point is approximately one-quarter the ship's length from forward. If the speed of the ship is reduced, the resistance created by the water ahead of the vessel will reduce and the pivot point will move aft. In shallow water, slowing a vessel with a large block coefficient such as the SunnyBlossom will also reduce the squat by the bow. Prelude to Grounding The radar coordinates taken at the approach to the bend between buoysD34 and D35 reveal that the SunnyBlossom was manoeuvred as anticipated, toward the south side of the channel. Adequate helm orders were given by the pilot and applied by the helmsman to reach the intended intermediate course, i.e. 247. The resistance encountered in continuing the course alteration to starboard is consistent with the influence of the strong current on the ship's bow, normally experienced at an outside bend of a channel. This force reduced the vessel's rate of turn to starboard and momentarily stopped it. The pilot, who was still using visual references, had anticipated this effect and, by giving the appropriate course orders, succeeded in making the vessel come around. As the vessel proceeded from the waterway into the narrow channel leading to the Lancaster Bar, the bow was closing on the shoal downstream of buoyD37 and the water depth was decreasing rapidly. When the heading was at 250G and the vessel reportedly cleared close to buoyD37, the heading should have been at 267G. Holding at 17off course, it was then that the pilot repeated his order for course 267G. At that instant, the vessel was moving ahead at about 5kn and the channel was at its shallowest. It is probable that helm changes to achieve course 267G for entry into the dredged channel should have been made either earlier or by using more rudder angle and that the bow was closer to the shoal than usual. As a result of the bow nearing, or perhaps glancing, this underwater barrier, the ship experienced a bank cushion effect. The positive pressure against the port bow, created by the build up of water, caused the vessel to sheer to starboard. This sheer was exacerbated by a main engine speed reduction and squat effect, which moved the theoretical pivot point of the ship further aft. In turn, this increased the turning lever created by the positive pressure ahead of the ship. Once the stern neared the side of the channel, the bank suction effect created another turning lever abaft the pivot point. Compounding these resultant horizontal forces was the starboard helm applied to reach the final course, 267G. With the probable loss of directional stability due to squat, the torque created by the resultant turning lever produced a sudden sheer to starboard, causing the vessel to overshoot. Electronic Chart System The ECS could not be used during the course of the voyage as it had not been calibrated with the GPS. Nor could the ECS be used on board the SunnyBlossom at the time of the previous grounding on 16July1999 (TSB report No. M99C0027), when the equipment was said to have been recently fitted but was not yet operational. Little progress, if any, had been made in the intervening year to render the system useful or to have the navigating officers properly trained. Although in-house training in the use of the system was being carried out by the deck officers, and the ECS was to be re-calibrated upon arrival in Cornwall, the effort to maintain the equipment in good order and to provide effective training in its use falls short of the intent of the IMO conventions and related recommendations. It is essential for users to complete IMO-recommended formal instruction. Maritime training centres have access to the IMO-recommended syllabus for ECDIS/ECS training, which can supplement any existing courses on the subject. It is incumbent upon the shipowner to ensure that equipment placed on board is functional and well maintained. Without formal training, the improper use of an ECS can be detrimental to the safe navigation of the vessel. There is no government approval on the use of this modern navigational aid as yet. However, had the ECS been functional and optimally positioned, and the officers well versed in its use, it would have provided the bridge team an additional tool to monitor the vessel's progress and a means to better maintain situational awareness under difficult conditions. Situational Awareness To maintain situational awareness, the navigator needs to refer to, or sample, a large amount of data from a variety of sources, both on board and external to the vessel. The SunnyBlossom was not equipped with a modern type of bridge layout. Those who controlled the vessel's movement had to look above the central forward window to see the helm indicator, look toward the starboard side of the bridge to confirm the engine telegraph setting, walk to the port side of the bridge to monitor the radars, and walk to the chart table abaft the central control panel to read the chart or monitor other navigation equipment. Just prior to the grounding, the pilot was standing at the forward bridge windows. Up to that time, conduct of the vessel had been done mainly by visual observation. The pilot concentrated his attention on visual cues, his primary source of information. The radar had been used as a secondary source, with the apprentice pilot providing information on the ship's heading and relative position. Visibility was reduced to 0.35 nm just eight minutes before grounding, by which time it had been further reduced to almost nil. When the rain intensified to the extent that visibility tended toward zero and the outside visual cues were obscured, the pilot's ability to project the vessel's track was reduced. His spatial and real-time resolution of visual cues was reduced. His only recourse was to monitor the on-board aids to navigation and instrumentation. By the time he had walked to the radars to confirm the vessel's heading and rate of turn, it was too late for him to correct the situation. Spatial disorientation may occur when information available from visual cues seems incomplete or contradictory. The solution to spatial disorientation is for the navigator to be continuously aware of, and to trust, the most reliable sources of information available, before visibility is reduced. In restricted visibility, these sources will invariably be the on-board aids to navigation and instruments. Bridge Resource Management To successfully negotiate the turn in the vicinity of buoy D35, it was necessary for the vessel to be positioned south of the centre of the channel to counter the effects of bank suction. However, this information was not shared with other members of the bridge team. This precluded the OOW from effectively participating in the navigation of the vessel. Consequently, when the third officer questioned the manoeuvre and received no response from the pilot, he acquiesced and the benefits of team synergy were lost. Close monitoring of a vessel's movement is critical to navigating safely in confined waters. Time is of the essence when initiating and executing manoeuvres. Therefore, it is essential that each bridge team member fully understands his/her role and ensures that any information that can favourably or adversely affect vessel navigation be communicated to the person in charge of pilotage/navigation. Not implementing Bridge Resource Management (BRM) precepts, such as effective communication or the exchange of information, has been identified in a number of occurrences.9 Concerned that a lack of BRM training among bridge personnel increases the probability of accidents in confined Canadian pilotage waters, the TSB issued recommendation M99-05, which requested that the Department of Transport and the Canadian pilotage authorities develop and implement a BRM training validation system to help ensure that the principles of BRM are being put into operational practice. Amendments to the General Pilotage Regulations came into force on 30March2000. Section11 of these regulations requires that, beginning on 01January2005, licences and pilotage certificate applicants or holders hold a certificate of attendance at a BRM training program recognized by the pilotage authority as meeting the requirements of PartB, ChapterVIII of the STCW Convention. The four pilotage authorities and the Canadian Marine Pilots Association have agreed to put into place a training committee within each region to examine all training requirements to ensure the continuous proficiency of pilots. A Pilot Continuous Proficiency Report, which contains specific training objectives for each pilot, including BRM, will be reviewed every five years, and a training initiative will be discussed with each pilot. The practice of BRM principles on the SunnyBlossom would have provided an opportunity to better the synergy of the bridge team and enhanced the effective tracking of the vessel's progress. Team awareness of the situation may have provided collective assistance to the navigators in attaining the correct course at the entrance to the dredged channel at an earlier stage. The SunnyBlossom was off course to port by approximately 17when it cleared buoyD37 upon entering the narrow dredged channel. The vessel experienced the effects in shallow water of squat at the bow and bank suction at the stern, which caused a loss of directional stability. Positive water pressure on the port bow as it encountered the south side of the channel, together with bank suction at the stern and starboard helm, caused the vessel to sheer suddenly to starboard. Action to correct the sheer was delayed due to the bridge team's difficulty in detecting the sheer in the conditions of restricted visibility. The sheer to starboard was not brought under control in time to avoid the vessel overshooting and grounding.Findings as to Causes and Contributing Factors The SunnyBlossom was off course to port by approximately 17when it cleared buoyD37 upon entering the narrow dredged channel. The vessel experienced the effects in shallow water of squat at the bow and bank suction at the stern, which caused a loss of directional stability. Positive water pressure on the port bow as it encountered the south side of the channel, together with bank suction at the stern and starboard helm, caused the vessel to sheer suddenly to starboard. Action to correct the sheer was delayed due to the bridge team's difficulty in detecting the sheer in the conditions of restricted visibility. The sheer to starboard was not brought under control in time to avoid the vessel overshooting and grounding. The vessel did not respond well to helm changes at half-ahead speed in shallow water, presenting the risk of grounding in narrow channels. An over-dependancy on visual aids, when visibility was steadily decreasing, reduced the navigators' situational awareness to the point where they became disoriented. The lack of Bridge Resource Management lessened the effectiveness of tracking the vessel and nullified any provision for the bridge team to assist the pilot in the navigation of the vessel.Findings as to Risks The vessel did not respond well to helm changes at half-ahead speed in shallow water, presenting the risk of grounding in narrow channels. An over-dependancy on visual aids, when visibility was steadily decreasing, reduced the navigators' situational awareness to the point where they became disoriented. The lack of Bridge Resource Management lessened the effectiveness of tracking the vessel and nullified any provision for the bridge team to assist the pilot in the navigation of the vessel.